This invention generally relates to a system or network for preparing and processing health care data transactions such as dental or medical insurance claims. More specifically, the present invention relates to such a system or network that is highly automated, very accurate and very simple to use.
The preparation and processing of health care data transactions such as insurance claims, especially medical and dental claims, has become a ubiquitous and aggravating procedure. For example, in 1993, approximately 3.6 billion medical insurance claims were filed, and an additional 387 million dental insurance claims were filed. Of these claims, over 2.3 billion claims were filed using paper claim forms.
In order to file just a single claim using paper forms, typically the patient and health care personnel provide a significant amount of data on one or more forms, and often this is done by hand printing or hand typing that data on the form or forms. For instance, the patient, or personnel at a health care facility, may complete one form, or a part of one form, by printing or typing on that form the patient's name, address and date of birth, information relating to the insurance company and information about the treated condition. Health care personnel then add information to that form, or another form, further describing the treated condition, describing the procedure or service received by the patient, and describing the individual providing that procedure and other related or supplemental information needed to process and adjudicate the claim.
After the appropriate form or forms are completed, they are mailed either to the insurance company or other carrier or to a third party administrator to be processed. In either case, upon receipt, the processor opens the envelope and manually inputs information on the forms into their own computers. Then, after a decision is made as to whether payment for the procedure is appropriate, and if so, the amount of such payment and the proper payee, a check is prepared and mailed to that payee. Additional manual labor may be needed to keep track of the total amount of claims submitted by each patient during a specified period and to keep track of other matters, such as for statistical purposes.
Not only is the preparation and processing of these paper forms time consuming and aggravating, it also adds substantially to the cost of health care. Another disadvantage of the paper forms is that errors are often made when the forms are filled out. For example, with some claims processing systems, up to 30% of the submitted claim forms have some type of error. This high percentage of errors is because, among other reasons, it is very easy to omit necessary information or to make mistakes when putting information on the forms. If data is missing from, or is not correct in, a claim form, then normally the form must be returned to its originator, causing additional work and delays in the processing of the claim.
Semi-automated procedures, using personal computers or other types of conventional computers, to prepare or to help prepare insurance claims or to process other health care data transactions are known. Typically, though, these procedures still require a significant amount of manual work, or require considerable computer operating skills. The requirements of these semi-automated procedures discourage people from using them. As a consequence, most people prefer the more time consuming and less accurate--but more familiar--routine of filling out paper forms by hand.